Georgia Overhauls Its Mental Health System

Georgia is the latest state to comply with a U.S. Supreme Court ruling to move mental health patients out of hospitals and into the community.

Past the security gate at the Northwest Georgia Regional Hospital in Rome, down a dim hallway littered with plastic bags full of shredded documents, a ringing phone echoes from an empty admissions office. Nobody answers. That’s because this psychiatric hospital has been shuttered. The 760-member staff is gone, along with all 180 patients who suffered from mental illness or developmental disabilities. The closure of the facility, which officially shut down for good on Sept. 30, is a big blow, according to Georgia state Rep. Barbara Massey Reece. “It was probably the most up-to-date mental health hospital in the state, so it was a shock to the entire community to learn that it was slated for closure.”

While the decision to close the hospital, which comprises 76 buildings spread over 206 acres, may have come as a surprise, the reasoning behind it dates back more than a decade. In 1999, the U.S. Supreme Court ruled that, under the Americans with Disabilities Act, all states must move individuals with mental illness out of ailing state-run institutions and into settings integrated with their communities. Keeping them segregated in an institution amounted to discrimination, the court said. Georgia didn’t listen. In a 2007 investigation, The Atlanta Journal-Constitution found that 130 patients at state-run hospitals had died under questionable circumstances over the course of seven years. That’s when the feds stepped in. Over the next two years, the U.S. Department of Justice looked into the conditions of Georgia’s mental hospitals. What federal investigators found was that patients in Georgia facilities were dying or committing suicide at alarming rates. What’s worse, the feds said, is that those incidents of neglect and abuse could have been prevented. The Justice Department sued the state to force it to improve the way it handled patients with mental disabilities. After a year of legal wrangling, Georgia and the federal government announced a settlement last fall.

Now, Georgia has been given its biggest mental health-care challenge in history. Under the settlement, the state must relocate 9,000 individuals with mental illness and 750 with developmental disabilities out of hospitals and into communities. The new model will include treatment teams in the field, government-supported housing and employment, wellness centers and peer-support programs, where people in the process of recovery can offer guidance and encouragement to one another. Those community-based facilities will be linked to a statewide system of comprehensive mental health services -- a system that’s far from complete.

It’s a huge undertaking, especially for an agency that’s only two years old. The Department of Behavioral Health and Developmental Disabilities (DBHDD) is a billion-dollar agency that was carved out of the state’s huge Department of Human Resources (now called the Department of Human Services) as a response to the federal pressure. That’s actually an advantage, says DBHDD Commissioner Dr. Frank Shelp. It gives the state the unique opportunity to start with a clean slate, he says, unaffected by the “fear, inertia and the resistance to change that can be baked into long-standing departments.”

By building its system from scratch, Georgia could emerge as an unlikely leader in mental health reform. Officials believe the state, which has traditionally ranked among the worst states for mental health care, could become a national model, helping set a precedent for how mental health systems can make a successful transition from an institutionalization approach to one based on recovery. “It’s very clear that many in the country are watching us,” Shelp says. “And there’s very much an expectation that we’re going to move from the back of the line to the front of the line.”

The push in the United States to move patients out of mental institutions dates back to the John F. Kennedy era. Starting with Kennedy’s support of a federal community mental health center model in 1963, state-run mental hospitals began to fall out of favor. Funded through medical insurance programs like Medicare and Medicaid, this new community-care model was intended to address the decades of overcrowding, lack of hygiene, and patient neglect and abuse that had characterized the worst government-run asylums. Rather than confining patients to years in cramped psychiatric hospitals, they would instead be able to live in neighborhoods, with access to quality mental health services.

But that’s not what happened. By the early 1980s, studies revealed thousands of patients released from state mental hospitals received no follow-up, treatment or assistance. In many states, smaller in-patient facilities like nursing homes and adult care homes became discharge destinations by default. And many of those facilities became the very institutions they were intended to replace, rife with neglect and abuse of those who needed help.

In 1990, President George H.W. Bush signed the Americans with Disabilities Act (ADA), a civil rights law to prohibit discrimination based on disability, including mental illness. Interpreting and applying that law has led to a continued debate over the value of deinstitutionalization. Sure, the notion of closing down long-term psychiatric wards sounds like a good idea. But if those patients are turned out into communities where support is scarce and resources are limited, as is sometimes the case, they can easily fall through the cracks. Many end up sleeping on the streets or locked up in jail. For that reason, a community-based model is far from a panacea, says Ron Honberg, national director for policy and legal affairs at the National Alliance for the Mentally Ill. “If we eliminate all in-patient options for people most severely ill, we end up relegating them to just as much misery through homelessness or incarceration -- institutions in the worst sense of the word,” Honberg says. “Closing hospitals before you have adequate care systems in place is a prescription for failure.”

Closing mental hospitals effectively cuts off the percentage of people with serious mental illnesses who actually need long-term attention and treatment, says William Fisher, a professor of psychiatry at the Center for Mental Health Services Research at the University of Massachusetts. Additionally, he says, those displaced patients who need the most attention will put an even higher strain on a state’s medical insurance costs. “What [Georgia is] doing is turning people loose on the Medicaid system,” he says. “In five years, God knows what that program is going to look like. To some extent, it’s a little like loading more passengers onto the Titanic.”

Still, those who advocate the closure of long-term care facilities say a community-care approach is the best way to accommodate individual needs. “One of the reasons why it has been historically difficult to change state service systems is that many people tend to assume that people in segregated settings must have really high needs,” says Jennifer Mathis, deputy legal director for the Bazelon Center for Mental Health Law in Washington, D.C. “But that hasn’t been borne out. When you treat people as people and allow them to thrive and be independent, they have self-confidence and begin to gain skills back and seem very functional.” The nonprofit Bazelon Center is one of the foremost proponents of community integration. In addition to leading a coalition of deinstitutionalization advocates in the Georgia case, Bazelon has been involved in similar suits in states from Connecticut to Mississippi to California. In 2003, the center served as co-counsel when Disabilities Advocates Inc. sued New York state over segregation in adult homes as a violation of the ADA. Last year a judge in the case ordered New York to develop sufficient, supported housing units for 4,000 adult home residents, but an appeal by the state has halted the transition.

In recent years, the federal government has become more aggressive about enforcing an integration model for mental health care. For one thing, the Obama administration has provided millions in vouchers to assist Americans with disabilities, and the Justice Department is working with state and local government officials, disability rights advocates, and health and human services representatives to enforce integration mandates. This July, the Justice Department informed the attorney general’s office in North Carolina that aspects of its system violated antidiscrimination law. North Carolina had been subsidizing the expenses of mental health patients living in adult care facilities. But the facilities had become overcrowded, according to the government: Nearly 6,000 patients had been packed into 288 homes. Just weeks before the North Carolina letter, the Justice Department reached an agreement with the state of Delaware over its mental health system. Under that settlement agreement, Delaware must move more than 3,000 individuals out of the state’s psychiatric hospital and state-funded private facilities by 2016. Similar to the agreement in Georgia, Delaware must develop a community-based system with supported housing, employment and a crisis network that includes mobile teams, crisis centers, a statewide hotline and peer-run programs. The state’s one psychiatric hospital won’t close. But in the future, patients will stay there a maximum of 14 days, except for a select few that the courts say need extraordinary attention.

But Georgia has much bigger problems -- literally. It’s the largest state east of the Mississippi River, and it includes rural areas that stretch for hundreds of miles. For now, six other mental hospitals remain open, but Northwest Georgia Regional served 31 counties in the northern part of the state. Mobile units in that area are only now just coming online. “Georgia has particular challenges because of the community system that’s poorly developed,” says the Bazelon Center’s Mathis. “If you have no functioning community system, you have to create it.”

In the past year, the state has placed 118 people with mental illness in supported housing, along with giving each of them about $2,300 for the first month’s rent, security deposits and furniture. Another 164 patients are in the pipeline, according to Tom Wilson, DBHDD’s director of communications. “By building a range of new community services for people with mental illness and focusing on available Medicaid waivers, we were able to find appropriate community placements for nearly all of the people who were being served” at the old Northwest Georgia Regional Hospital, Wilson says.

Still, Rep. Reece says she worries that, in closing down the entire facility, the state may be moving too far in the community-model direction. Georgia’s agreement with the federal government only involved setting up a new mental health system, not necessarily dismantling the existing one. Now that Northwest Regional has closed, the nearest psychiatric care hospital is 65 miles away in Atlanta. That’s a disservice to patients who do need long-term care and close supervision, Reece says. “The groundwork has not been laid” for the new system, Reece told reporters earlier this year, adding that the state should “slow down and make sure what kind of support is out there for these patients.”

The greatest uncertainty is simply that there’s no way to know what the system will really look like years down the line. The deinstitutionalization push that states are making today could have unintended consequences in the future. “When you start changing a system of care, it’s like a waterbed,” says Kevin Ann Huckshorn, state director for the Division of Substance Abuse and Mental Health in Delaware’s Department of Health and Human Services. “You can’t predict what will happen when you sit on the edge.”